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<head>
	<meta http-equiv="Content-Type" content="text/html;charset=utf-8" />
	<title>体检预约服务平台 - 医通在线</title>
	<link href="templates/css/global.css" rel="stylesheet" type="text/css" />
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</head>
<body>

<!--header st-->
<{include file="../templates/$newtpl/header.html"}>
<FORM style="margin-top:5px" action="/index.php?action=family_2"  method="post" enctype="application/x-www-form-urlencoded" name="appendform" target="_self" id="appendform">
<div class="row mb10 center_layout fix">
	<{include file="../templates/$newtpl/left.html"}>
	<div class="grid0 grid770">
		<div class="main_con">
			<div class="subline"><h4>家属预约登记</h4><!-- <a href="<{$__URL__}>help" target="_blank" class="yuyue"><s></s>预约须知</a> --></div>
			<div class="step"><img src="templates/images/buy/step_1.png" /></div>
			<div class="con info_box">
				<dl class="form">
					<dd><label class="label"><em class="red">*</em>体检人姓名：</label><input name="name" type="text" class="input" id="name" /><span style="color:red;font-size=12px;">(必填)</span></dd>
					<dd><label class="label">有效证件：</label>
					  <input name="type" type="radio" value="1" checked>
					  身份证
					  <input type="radio" name="type" value="2" >
					  护照
					  <input type="radio" name="type" value="3">
					  军官证
					  <input type="radio" name="type" value="4">
					  其他
					</dd>
                   <dd><label class="label"><em class="red">*</em> 证件号：</label><input name="code" type="text" class="input" id="code"   /><span style="color:red;font-size=12px;">(必填)</span></dd>

					<dd><label class="label"><em class="red">*</em>性别：</label><input name="sex" type="radio" value="1" />
					  男<input name="sex" type="radio" value="2" />
					  女<span style="color:red;font-size=12px;">(必选)</span></dd>


                        <dd>
                        <label class="label">出生日期：</label><input name="birthday" onFocus="WdatePicker({lang:'zh-cn',startDate:'1980-01-01'})" type="text" class="input" id="birthday" onFocus="WdatePicker()"/><span class="">体检机构需要登记您的年龄，格式YYYY-MM-DD
                        </span>
                        </dd>

					<dd><label class="label"><em class="red">*</em> 婚姻状况：</label><label class="mr20"><input name="wedding" type="radio" class="radiobtnfix"  value="1" checked="checked">未婚</label><label><input name="wedding" type="radio" class="radiobtnfix" value="2"/>已婚</label>
                                            <!--<span style="color:red;font-size=12px;margin-left: 10px;"><br />&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;已婚女性套餐比未婚套餐增加 阴超、白带常规、宫颈刮片，未婚女性做已婚套餐需在体检中心前台签字确认。</span>-->
					</dd>
					<dd><label class="label"><em class="red">*</em> 手机：</label><input name="tel" type="text" class="input" id="tel" onkeyup="value=value.replace(/[^\d]/g,'') " onbeforepaste="clipboardData.setData('text',clipboardData.getData('text').replace(/[^\d]/g,''))" />

						<span class="fault">(必填)&nbsp;&nbsp;确保您能收到预约短信提醒，请准确填写手机号！</span>
					</dd>
					<dd><label class="label">邮箱：</label><input name="email" type="text" class="input" id="email"  /></dd>

				</dl>

					<span style="color:#FF0000;">
						重要提示：此次体检为实名制体检，请您正确填写家属个人资料，一旦预约成功，家属信息将不能在线修改，如需修改请致电400-820-6772-1-3。
					</span>
				
				<div class="btn"><a href="###" onClick="jumpto_family_2();" title="下一步" class="btn_next"></a></div>
		  </div>
		</div>
	</div>
</div>
</form>
<{include file="../templates/$newtpl/foot.html"}>

<!--脚本如下-->
<script src="templates/js/jquery-1.7.2.min.js" type="text/javascript"></script>
<script src="templates/js/jquery.switchable2.min.js" type="text/javascript"></script>
<script src="templates/js/global.js" type="text/javascript"></script>

<script type="text/javascript">

	$('#slideBox .log_box').switchable({
		triggers: $('#slideBox .tab li a'),
		panels: '.tab_con',
		triggerType: 'click'
	});
$(function(){
    $('input[name=invoice]:radio').click(function(){
        if( $(this).val() == 1){
            $('#invoiceDd0,#invoiceDd1,#invoiceDd2').removeClass('dn');
        }else{
            $('#invoiceDd0,#invoiceDd1,#invoiceDd2').addClass('dn');
        }

    });

});

</script>

</body>
</html>